Contemporary Behavioral Approaches: Techniques and
ResultsDebra Braunling-McMorrow, Ph.D.
V.P. DevelopmentNeuroRestorative
PURPOSE
• Understand Contemporary Rehab. And Behavioral Themes
• Understand the importance of antecedent based approaches in responding to and preventing behavioral issues
• Understand Behavioral Sequences and the Importance of Windows of Opportunities in Providing Support
• Use Personal Intervention and Other Approaches• Achieve Meaningful Outcomes
SOME BEHAVIORAL ISSUES AFTER ABI
• Diminished awareness of difficulties• Predictable topic/situations that produce upset• Tendency to rationalize or blame others for problems• Tendency to perseverate during upsets• Others “walk on eggshells”• Diminished Problem solving skills under stress• Difficulty receiving “corrective” feedback• Resistance to traditional rehabilitation agendas• Behaviors that produce risk to self or others• Post injury Experience with “Behavior Management”
Where are people with brain injuries who have
behavioral issues?…………
BRAIN INJURY AMONG THE HOMELESS
• MN Plan to End Long-Term Homelessness– Of 1,320 homeless individuals, 39% report possible BI.
(Heading Home project April, 2008)
• Assessment of 100 homeless men in NY found 82% suffered brain injury in childhood, primarily as a result of parental abuse (Gordon, et. Al., 2006)
• 23% of homeless population are veterans– 47% Vietnam era– 67% served 3 or more years– 89% received Honorable Discharge
(Interagency Council on the Homeless, 1999)
BRAIN INJURY AMONG PRISONERS
• Studies indicate TBI occurs among an estimated 25-87% of the jail and prison population (Walk. Helgeson, Langlois, Brain Injury Professional, 2008)
• In contrast, to an estimated 8.5% of non-incarcerated adults (Silver, et. Al., 2001)
SOME CONTEMPORARY THEMES IN BEHAVIORAL INTERVENTION
• Outcome Driven• Proactive/Non-Intrusive• Person Centered• Self-Managed• Interactional• We all wear the hat of a behavior analyst
SOME BASES OF BEHAVIORAL INTERVENTION
• Thoughts, Feelings and Actions are “things”• “Things” happen for a Reason… they are caused• Sometimes we can change “things”• We make decisions whether behavior is “good” or
“bad”• There are two main ways to change “things”
(Stop old or Start new)• Contemporary Themes influence Practice
APPROACHES TO BEHAVIOR CHANGE
ONE WAY ANOTHER WAYFocus Single Behavior Complex SequenceGoal Reduce Inappropriate Increase AppropriateStyle Reactive Proactive
Timing Consequence (After) Antecedent (Before)Intent Provider Control Personal ControlLocale Excluded Site Included Site
Purpose Manage Behavior Empower ParticipantFlavor Impersonal Mutually Reinforcing
CHANGING BEHAVIORHaving an impact on the things that happened
before or after behavior
1. Discouraging “old ways” of behaving after they occur (REACTIVE APPROACH)
2. Removing certain causes as behavior is happening (PASSIVE APPROACH)
3. Encouraging new ways of behaving when the causes show up (PROACTIVE APPROACH)
PREDISPOSITIONSWe are all “predisposed” to behave in particular
ways based on “what we bring with us” to a particular situation. Persons with ABI bring a complex combination of pre and post-injury
factors.
SOME PREDISPOSING FACTORS: Learning History, Medical Conditions, Medications, Neurological Status, History of Trauma, Substance Exposure, Treatment History, Sleep Deprivation, Interactional History, Emotional Backdrop, Environmental Stimulation, etc.
ANTECEDENTSEvents that occur in some temporal proximity to the
behavioral sequence of interest that are believed to play a causal role in their onset
SOME POTENTIAL ANTECEDENTS: Difficult Tasks, Particular Individuals, Environmental Conditions (e.g., heat, clutter, noise, etc.), Presence of Desired Objects, Particular Interactions (e.g., criticism, public corrections, competition, etc.)
WHEN THE “HEAT COMES ON THERE ARE FOUR GENERAL WAYS THAT PEOPLE CAN RESPOND…
1. ESCAPE OR AVOID2. WITHDRAY OR “FREEZE”3. GET EMOTIONAL4. PROBLEM-SOLVE
• ACTING ANY OF THESE WAYS MAY SERVE TO MAKE A DIFFICULT SITUATION LESS DIFFICULT
• THE PROBABILITY OF 1, 2, & 3 ARE IMPACTED BY AN INDIVIDUAL’S ABILITY TO PROBLEM-SOLVE
PERSONAL INTERVENTION AT A GLANCE
HIGH
LOWTIME
AROUSAL
From McMorrow, 1994
NOW IS TIME FOR ACTIVE TREATMENT AND
PERSONAL INTERVENTION
NOW IS TIME FOR RISK MANAGEMENT
An escalating sequence of behavior
TREATMENT APPROACHES• Philosophical Stands and Commitments• Residential Array or Continuum• Interactional Style / Proactive De-escalation• Integrated Staffing and Service Delivery• Personal Intervention Training• Goal Setting Activities• Functional Cognitive Rehabilitation• Performance Monitoring• Risk Management / Com. Access Review
STANDS AND COMMITMENTS OF A PROACTIVE APPROACH
• Emphasis on Positive/Mutual Reinforcement• Avoidance of methods based on punishment,
extinction, or escape-extinction learning operations
• Minimal medication regimen and no PRN’s• Least restrictive treatment (no fooling!)• No mechanical restraint or exclusive/seclusion• Keep participants involved in the life of their
community• Treat all participants with respect and dignity (no
matter what…)• Include “stands” as a part of quality assurance
measures
THEMES OF PROACTIVE REHABILITATION
• Create pathways to obtain preferences• Establish “type 2” reinforce-reinforce reciprocity• Establish problem-solving skills in difficult
situations• Increase probability of problem-solving by
maintaining low arousal• Graduate exposure to more difficult situations to
enhance experience of success
INTERACTIONAL “DO’S”(interacting with confused and agitated)
• GET YOURSELF ORIENTED• DEVELOP A CHARACTERISTIC INTERACTIONAL
STYLE• GRADUATE EXPOSURE TO ENVIRONMENT,
OPPORTUNITIES, REHAB EXPECTATIONS• ENCOURAGE SAFE EXPLORATION• DISCOVER PREFERENCES• LEARN TO “LISTEN”• BOUNCE BACK QUICKLY FROM PROBLEMS• REACH AGREEMENTS
RECIPROCITY GOES BOTH WAYS
RECIPROCITY IS AN ONGOING EXCHANGE OF SIMILAR INTERACTIONS.
(THERE ARE TWO TYPES OF RECIPROCITY)
1. ATTACK – ATTACK/NEGATIVE(“EYE FOR AN EYE”)
2. REINFORCE – REINFORCE/POSITIVE(YOU SCRATCH MY BACK AND I’LL SCRATCH YOURS)
Eye For An EyeWill Make the Whole
World Blind Gandhi
COMPONENTS OF ACTIVE TREATMENT INTERACTION
P Positive
E Early
A All
R Reinforce
L Look
_________
PEARL
McMorrow & Kirkpatrick, 94
SOME BEHAVIORAL DE-ESCALATION PROCEDURES
RESPONSE PRIMING
REFELCT AND REASSURE
STIMULUS CHANGE (X2)
INTERSPERSED REQUESTS
FOCUSED REDIRECTION
REINFORCER RECALL
TOPIC DISPERSAL
FUNCTIONAL REPLACEMENT
BEHAVIORAL MOMENTUM
COMPONENT OF A PERSONAL INTERVENTION PLAN
An individualized compensatory strategy for managing emotions and behavior
in difficult situations
• LIST PREDISPOSING FACTORS• LIST EVENTS OR ANTECEDENTS TO UPSETS• IDENTIFY SEQUENCE OF UNWANTED BEHAVIOR• LIST DESIRE REPLACEMENT BEHAVIOR• IDENTIFY SUPPORT NEEDED FROM OTHERS
WHAT IS PERSONAL INTERVENTION?
1. An individual plan for managing one’s emotions and behaviors in difficult situations.
2. A contemporary way of teaching behavioral self-management and providing support for persons who are learning.
3. A compensatory strategy for persons who have difficulty problem-solving in high arousal conditions.
A Simple Personal Interventions Plan for ________
This plan is intended to assist you and those who may help you to learn more about yourself and get better at managing your emotions and behavior when the going gets tough. Consider it as a representation of ways you have responded in the past and a new
start on waysyou may use it in your future.
1. I am likely to have a bad day when…(List at least three situations that may precede a “bad day.”)
2. I am likely to get upset when…(List at least five events that produce upset for you.)
3. When I get upset, I notice a sequence that starts with __________ and may end with ___________.(Make a list from the first sign to other things that do or could occur.)
4. When I notice that a difficult situation is coming or when I begin to get upset, I will have the most success when I…(List the steps you need to take.)
5. Other people can help me by…(Identify who you need to help and list what you need them to do.)
Center for Comprehensive Services, Inc.Abbreviated Summary of the Functional Area Outcome Menu1
Level ofFunctioning
ResidentialStatus
Level ofIndepend.
BehavioralAnd
EmotionalStatus
CommunityParticipa-
tion
Level ofAwareness
VocationalEndeavors
EducationalEndeavors
InvolvementIn
Vocation orEducation
Level ofSelf
ManagedHealth
IntimacyRelation-
ships
QualityOfLife
5Maximum
At homeandIndependent
CompletelyIndependent17-24 hrsper day
Selfmanageswith noassistance
Productiveactivitiesdaily
Anticipatoryawareness,canconsistentlyplan ahead
Competitiveemployment
Regularclassroom
Full-timeparticipation
SelfInitiatesmedicalroutines
Mutuallysatisfyingrelationshipintimacyand friends
High qualityof life
4 Home orapartmentwith support
Independ.9-16 hoursper day
Selfmanageswithoccasionalassistance
Productiveactivities,but notdaily
Emergentawareness,maysometimesplan ahead
Noncompetitiveorsupportedemployment
Classroomwithformalsupport
¾ timeparticipation
Requiresdirectionguidancefor complexmedicalissues
Reportsrelationshipwith friendsor intimate> 1 time/wk.
Person isoften happy
3Intermediate
Congregateliving.Staffavailable24 hrs/day
Independ.5-8 hoursper day
Selfmanageswith dailyassistance
Errands andleisureactivitiesweekly
Intellectualawareness,inconsistentlyinitiatesstrategies
Shelteredorspecializedemployment
Selfcontainedclassroom& regularclassroom
½ timeparticipation
Managesbasicmedicalonceprompted
Casualrelationship,activitiesout of homeat least1 time/wk.
Generallyhappyexhibitsproblemsdealing withday to day
2 Post-AcuteRehab.setting
Independ.up to 4 hrs.per day
Minimallyresponsiveto externalintervention
Errands,leisureactivitiesone timeper weekor more
Identifiesskill anddifficultiesonceprompted
Avocationalprogram
Selfcontainedclassroomonly
¼ timeparticipation
No selfmanagementskills ofmedicalroutines
Interactswith othersonly forbasic needs
Person israrelyhappyDifficultywith day today issues
1Minimum
Institutionalsetting
Requires24 hourassistance
Activelyresistsexternallymanagedinterventions
Nocommunityparticipation
Cannotidentifyany skill ordifficulties
Noparticipation
Noparticipation
Noparticipation
Resistant tomedicalinterventions
No contactor activelyresistscontact
Person isconsistentlyunhappy ormiserable
1 Braunling-McMorrow, D. & Tompkins, S. (1994). Measuring outcomes: A model for post-acute rehabilitation programs for persons with TBI. Center for Comprehensive ServicesMonograph, 1(4). Carbondale, Illinois: Center for Comprehensive Services, Inc.Revised Braunling-McMorrow, D. Neumann, T.(1999)
Functional Areas
NeuroBehavioral Programs
1
2
3
4
5
Reside
ntial
Indep
ende
nce
Behav
ior
Communit
y
Awaren
ess
Vocati
on
Educa
tion
Involv
emen
t
Quality
Health
Relatio
nship
s
Total persons admitted - 676Total persons one year follow-up - 227
Leve
l of I
ndep
ende
nce
REHAB GROUP X INTERACTION
0.5
0.75
1
1.25
1.5
1.75
<6 mo 6-12 mo >12 mo
TPI Group
Gai
n So
lo
NB
Thank YouDebra Braunling-McMorrow, Ph. D.
Vice President DevelopmentNeuroRestorative
(formerly MENTOR ABI)
Suggested Readings:Getting Ready to Help: A Primer on Interacting in Human
ServiceM. J. McMorrow, Brookes Publishing 2003www.brookespublishing.com
BRAIN INJURY PROFESSIONAL 2009 VOL 5(4) BEHAVIOR: RESPECTING INDIVIDUALITY AND PROMOTING ABILITY
NORTH AMERICAN BRAIN INJURY SOCIETY
BEHAVIORAL CHALLENGES AFTER BRAIN INJURY, 2007BIAA www.biausa.org
LASH AND ASSOCIATES PULISHING AND TRAININGwww.lapublishing.com